Form 1.1 HIV

Attachment 1.1

OMB No. (0925-xxxx), Expiration Date (xx/xx/xxxx)

RETROVIRUS EPIDEMIOLOGY DONOR STUDY-II (REDS-II)

HIV RISK FACTOR QUESTIONNAIRE

Thank you for taking the time to help us with this important study. Participation in this study is entirely voluntary. You may refuse to participate now, or at any time during the process. Refusal to participate in the study or withdrawing from the study will involve no penalty.

You do not have to answer any questions you do not wish to, and you may stop at any time. You may refuse to answer any question(s) that make(s) you feel uncomfortable or upset(s) you.

Date: __ __/__ __/__ __ __ __ (D D/ M M / Y Y Y Y)

Study identification number: __ - __ __ __ __ __ __ __ - __

When were you born?	19__ __ (year)
What is your gender?	1 Female 2 Male
What is your place of birth?	___________ ______________ City/county Province
What is your ethnicity?	1 Han 2 Hui 3 Uygur 4 Man 5 Dai 6 Other, specify ______________
What is your current occupation?	1 Worker 2 Farmer 3 Business 4 Service 5 Education/research/government 6 Military/Police 7 Medicine/Health care 8 Student 9 Other, specify _____________
6. What is the highest level of education you have received?	1 Primary school or less 2 Junior high school 3 High School or vocational school 4 Bachelor’s degree 5 Graduate level degree 6 Other, specify _____________
7. What is your marital status?	1 Never married 2 Married 3 Divorced 4 Separated 5 Widowed 6 Other, specify _____________
8. How many times have you donated blood? a. Year and type of each blood donation (If you have donated blood more then 4 times, please list the most recent three)	__ __ time (s) 1. __ __ __ __ (year) Donation type: Whole blood donation Apheresis donation 2. __ __ __ __ (year) Donation type: Whole blood donation Apheresis donation 3. __ __ __ __ (year) Donation type: Whole blood donation Apheresis donation
9. How much do you agree or disagree about phrases below: It’s important that I received blood test results from blood donation. I think blood donation is a good, fast, anonymous way to get my blood test. One of my reasons for donating blood is to find out if I have HIV and/or hepatitis infection.	1 Do not agree at all 2 Disagree a little 3 Agree a little 4 Agree very much 1 Do not agree at all 2 Disagree a little 3 Agree a little 4 Agree very much 1 Do not agree at all 2 Disagree a little 3 Agree a little 4 Agree very much
10. Have you ever received acupuncture treatment? a. In the 12 months before your most recent donation, did you have acupuncture?	1 Yes  ANSWER QUESTION a 2 No SKIP TO 11 99 Unknown  SKIP TO 11 1 Yes 2 No 99 Unknown
11. In the 12 months before your most recent donation, did you have any injection (including intravenous and intramuscle injections)? a. How many times did you have injection(s)?	1 Yes  ANSWER QUESTION a 2 No SKIP TO 12 99 Unknown  SKIP TO 12 __ __ times
12. Have you had any finger sticks? a. In the 12 months before your most recent donation, did you have finger sticks?	1 Yes  ANSWER QUESTION a 2 No SKIP TO 13 99 Unknown  SKIP TO 13 1 Yes 2 No 99 Unknown
13. Have you ever had in-patient medical surgery? a. In the 12 months before your most recent donation, did you have in-patient medical surgery?	1 Yes  ANSWER QUESTION a 2 No SKIP TO 14 99 Unknown  SKIP TO 14 1 Yes 2 No 99 Unknown
14. Have you ever had out-patient medical surgery? a. In the 12 months before your most recent donation, did you have out-patient medical surgery?	1 Yes  ANSWER QUESTION a 2 No SKIP TO 15 99 Unknown  SKIP TO 15 1 Yes 2 No 99 Unknown
15. Have you ever had cosmetic surgery (e.g. laser, eye/lip surgery, collagen injection, dermal abrasion)? a. In the 12 months before your most recent donation, did you have cosmetic surgery?	1 Yes  ANSWER QUESTION a 2 No SKIP TO 16 99 Unknown  SKIP TO 16 1 Yes 2 No 99 Unknown
16. Have you ever received a blood transfusion? a. How many times did you have blood transfusions? b. Year of your first time of blood transfusion? c. Year of your last time of blood transfusion?	1 Yes ANSWER a, b AND c 2 No SKIP TO 17 99 Unknown  SKIP TO 17 __ __ times __ __ __ __ (year) __ __ __ __ (year)
Have you ever had any dental cleaning? a. In the 12 months before your most recent donation, did you have dental cleaning?	1 Yes ANSWER QUESTION a 2 No SKIP TO 18 99 Unknown  SKIP TO 18 1 Yes 2 No 99 Unknown
Have you ever had any dental surgery, such as root canal treatment or tooth extraction? a. In the 12 months before your most recent donation, did you have dental surgeries?	1 Yes ANSWER QUESTION a 2 No SKIP TO 19 99 Unknown  SKIP TO 19 1 Yes 2 No 99 Unknown
Have you ever had any endoscopy (such as gastroscopy and colonoscopy)? a. In the 12 months before your most recent donation, did you have endoscopies?	1 Yes ANSWER QUESTION a 2 No SKIP TO 20 99 Unknown  SKIP TO 20 1 Yes 2 No 99 Unknown
20. When you had acupuncture, finger sticks, or injections, were needles and syringes used disposable?	1 Seldom 2 Sometimes 3 Often 4 Always 99 Unknown
21. Have you ever been told that you are at risk for spreading diseases through your blood?	1 Yes 2 No 99 Unknown
22. Have you ever been deferred as a blood donor? a. For what reason were you deferred?	1 Yes ANSWER QUESTION a 2 No SKIP TO 23 99 Unknown  SKIP TO 23 Specify ______________________
Have you ever been previously diagnosed with hepatitis? a. What type(s) of hepatitis did you have?	1 Yes ANSWER QUESTION a 2 No SKIP TO 24 99 Unknown  SKIP TO 24 1 HAV 2 HBV 3 HCV 4 Other, specify _____________ 99 Unknown
24. Have you ever been previously diagnosed with syphilis, gonorrhea, or any other sexually transmitted disease?	1 Yes 2 No 99 Unknown
25. Have any of your family members had hepatitis?	1 Yes 2 No 99 Unknown
26. Have any of your family members had HIV/AIDS?	1 Yes 2 No 99 Unknown
27. Have you ever had household contact with someone with hepatitis or HIV/AIDS? a. In the 12 months before your most recent donation, did you have household contact with someone with hepatitis or HIV/AIDS?	1 Yes ANSWER QUESTION a 2 No SKIP TO 28 99 Unknown  SKIP TO 28 1 Yes 2 No 99 Unknown
28. Have you ever used needles to shoot street drugs? a. How long have you shot drugs? b. How many times per month did you shoot drugs? c. Have you ever shared needles or syringes with others to inject street drugs?	1 Yes ANSWER a, b AND c 2 No SKIP TO 29 99 Unknown  SKIP TO 29 __ __ years __ __ times/month 1 Yes 2 No 99 Unknown
29. Have you ever used illegal oral or intranasal drugs without doctor’s prescription? a. In the 12 months before your most recent donation, did you use illegal oral or intranasal drugs without doctor’s prescription?	1 Yes ANSWER QUESTION a 2 No SKIP TO 30 99 Unknown  SKIP TO 30 1 Yes 2 No 99 Unknown
30. Have you ever lived with a person with illegal injection? a. In the 12 months before your most recent donation, did you live with a person with illegal injection?	1 Yes ANSWER QUESTION a 2 No SKIP TO 31 99 Unknown  SKIP TO 31 1 Yes 2 No 99 Unknown
31. Are any of your close friends or family members intravenous drug users?	1 Yes 2 No 99 Unknown
32. Have you had 2 or more sexual partners of the opposite sex? a. How many heterosexual partners did you have? b. How often do you or your sex partner use a condom when you have sex with your heterosexual partner?	1 Yes ANSWER a AND b 2 No SKIP TO 33 99 Unknown  SKIP TO 33 1 2-4 2 5-7 3 8-10 4 >10 1 Never 2 Sometimes 3 Half of time 4 Most of time 5 Always
33. (For male only) In your lifetime, have you ever had sex with another male? a. How many times did you have sex with males? b. How many male partners have you had sex with? c. How often do you or your sex partner use a condom when you have sex with male partner?	1 Yes ANSWER a, b AND c 2 No SKIP TO 34 99 Unknown  SKIP TO 34 __ __ times __ __ partners 1 Never 2 Sometimes 3 Half of time 4 Most of time 5 Always
34. Have you ever paid or received money for having sex? a. How many times have you paid or received money for having sex? b. In the 12 months before your most recent donation, did you pay or receive money for having sex?	1 Yes ANSWER a AND b 2 No SKIP TO 35 99 Unknown  SKIP TO 35 __ __ times 1 Yes 2 No 99 Unknown
35. Have you ever had a sex partner that was an intravenous drug user? a. In the 12 months before your most recent donation, did you have a sex partner that was an intravenous drug user?	1 Yes ANSWER QUESTION a 2 No SKIP TO 36 99 Unknown  SKIP TO 36 1 Yes 2 No 99 Unknown
36. In the past ten years, have you ever had a sex partner who had a positive test for syphilis, gonorrhea, or any other sexually transmitted disease? a. In the 12 months before your last donation, did you have a sex partner who had a positive test for syphilis, gonorrhea, or any other sexually transmitted disease?	1 Yes ANSWER QUESTION a 2 No SKIP TO 37 99 Unknown  SKIP TO 37 1 Yes 2 No 99 Unknown
37. In the past ten years, have you ever had a sex partner who had been diagnosed with hepatitis or HIV/AIDS? a. In the 12 months before your most recent donation, did you have a sex partner who had been diagnosed with hepatitis or HIV/AIDS?	1 Yes ANSWER QUESTION a 2 No SKIP TO 38 99 Unknown  SKIP TO 38 1 Yes 2 No 99 Unknown
38. In the past one year, have you had sexual contact with anyone who received blood transfusion? a. In the 12 months before your most recent donation, did you have sexual contact with anyone who received blood transfusion?	1 Yes ANSWER QUESTION a 2 No SKIP TO 39 99 Unknown  SKIP TO 39 1 Yes 2 No 99 Unknown
39. Have you ever contacted with human blood and other human body fluids in your workplace? a. In the 12 months before your most recent donation, did you contact with human blood and other human body fluids in your workplace?	1 Yes ANSWER QUESTION a 2 No SKIP TO 40 99 Unknown  SKIP TO 40 1 Yes 2 No 99 Unknown
40. Have you ever had a tattoo? a. In the 12 months before your most recent donation, did you have a tattoo?	1 Yes ANSWER QUESTION a 2 No SKIP TO 41 99 Unknown  SKIP TO 41 1 Yes 2 No 99 Unknown
41. Have you ever had your ears or other body parts pierced? a. In the 12 months before your most recent donation, did you have your ears or other body parts pierced?	1 Yes ANSWER QUESTION a 2 No  SKIP TO 42 99 Unknown  SKIP TO 42 1 Yes 2 No 99 Unknown
42. Did you receive notification from blood center about your infection status? a. Did you seek further testing or health care according to the instruction of the notification? b. Are you planning to seek further testing or health care according to the instruction of the notification?	1 Yes ANSWER a AND b 2 No END 99 Unknown  END 1 Yes  END 2 No  ANSWER QUESTION b 99 Unknown  END 1 Yes 2 No 99 Unknown

Thank you very much for your participation!

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